Ocular Manifestat

ions of

Systemic Diseases

Dr.Turki AL-TurkiConsultant Ophthalmlogist

THE EYE & THE BODY

NORMAL FUNDUS

Cardiovascular diseases

Flame shaped hemorrhages

Flame shaped hemorrhages

Cotton wool spots

Hard exudates

Grade IV Hypertensive Retinopathy Central retinal vein occlusion

Branch retinal vein occlusion

Second most common cause of vascular-related visual loss.

Risk factorsHypertension CoagulopathyVasculitis (Behcets,sarcoidosis,AIDS,SLE)

Diagnostic workup BP measurement Lipid profile ECG Echocardiography Carotid Doppler

Consider risk factors Hypertension Carotid artery diseases Cardiac Arrhythmias Coagulopathy

Cardiovascular diseases

Central retinal artery occlusion

OCULAR EMERGENCY

Diabetes MellitusA cause of 4000 new case of blindness/year.Risk factors

• Family history• Duration of disease• Type of DM• Use of insulin• Poor metabolic control• Presence of Co-morbid conditions

HypertensionHyperlipidemiaRenal diseaseSmokingAlcohol consumptionAnemiaObesityPregnancy

Mild non-prolifrative diabetic retinopathy Moderate non-prolifrative diabetic retinopathy

Sever non-prolifrative diabetic retinopathy

Proliferative diabetic retinopathy

Tractional retinal detachment

• Argon laser pan-retinal photocoagulation (PRP).

• Focal laser treatment for macular edema.• Intravitreal injection of steroids• Intravitreal injections of anti-vascular

endothelial growth factor (Anti-VEGF)

• Third (Oculomotor) cranial nerve palsy.

Diabetes Mellitus

Complete 3rd nerve palsy

MAKE SURE THAT THE PUPIL IS NORMALLY REACTING IN 3RD NERVE PALSY

Thyroid eye disease

Unilateral lid retractionUnilateral proptosis

Bilateral lid retractionBilateral proptosis

In 50% of cases

1. Soft tissue involvement• Periorbital and lid swelling• Conjunctival hyperemia• Chemosis• Superior limbic keratoconjunctivitis

2. Eyelid retraction3. Proptosis4. Optic neuropathy5. Restrictive myopathy

Thyroid eye disease

Lid lag on down gaze movement

Proptosis

Treatment options • Systemic steroids • Radiotherapy • Surgical decompression

• Occurs in about 50% • not influenced by treatment of hyperthyroidism

Axial and permanent in about 70% May be associated with choroidal folds

Soft tissue involvementPeriorbital and lid swelling

Chemosis

Conjunctival hyperaemia

Superior limbic keratoconjunctivitis

Optic neuropathy• Occurs in about 5% • Early defective colour vision • Usually normal disc appearance

Caused by optic nerve compression at orbital apex by enlarged recti muscles Often occurs in absence of significant

proptosis

• Occurs in about 40% • Due to fibrotic contracture

Restrictive myopathy

Elevation defect - most common Abduction defect - less common

Depression defect -uncommon Adduction defect - rare

Inflammatory conditions(Sarcoidosis)

• Idiopathic multisystem disorder• Characterised by non-caseating

granuloma• More common in women 20-50 yrs• More common in blacks and Asians• Eyes – 30%

Inflammatory conditions(Sarcoidosis)

Anterior segment lesions (30%)• Conjunctival granuloma• Acute or chronic uveitis• Lacrimal gland involvement& dry eye

Posterior segment lesions (20%)• Patchy venous sheathing• Cellular infiltrate around vessels• Chorioretinal granulonmas• Vasculitis• Neovascularisation• Infiltrate in vitreous (vitritis)

Sickle cell retinopathy

New vessel formation Sea fan neovascularizationHyphema

Leukemia

White centered hemorrhage (Roth’s spot)Sterile hypopyon

Metastatic renal cell carcinoma Metastatic lymphoma

Metastatic lung cancer

Metastasis

Neurofibromatosis type-1 (NF-1)

Most common phacomatosisAffects 1:4000 individualsPresents in childhood

Café-au-lait spots

Appear during first year of lifeIncrease in size and number throughout

childhood

Eyelid neurofibromas in NF-1

Nodular Plexiform

May cause mechanical ptosis May be associated with glaucoma

Intraocular lesions in NF-1Lisch nodules

Very common - eventually present in 95% of cases

Congenital ectropion uveae

Uncommon - may be associated with glaucoma

Retinal astrocytomas

Rare - identical to those seen intuberous sclerosis

Choroidal naevi

Common - may be multifocal and bilateral

Ocular features of NF-2

Common - combined hamartomas of RPE and retina

Very common -presenile cataract

Peripheral corneal involvement in Rheumatoid arthritis,Wegener granulomatosis, polyarteritis nodosa

• Chronic and asymptomatic• Circumferential thinning with intact

epithelium (‘contact lens cornea’)

• Acute and painful• Circumferential ulceration and

infiltration

Treatment - systemic steroids and/or cytotoxic drugs

Without inflammation With inflammation

GIANT CELL ARTERITIS

• Headache• Scalp tenderness• Thickened temporal arteries• Jaw claudication• Acute visual loss• Weight loss, anorexia, fever, night

sweats, malaise & depression

Ocular Complications• Transient monocular visual loss

(amaurosis fugax)• Visual loss due to

– Central retinal artery occlusion (CRAO) or

– Anterior ischaemic optic neuropathy (AION)

• Visual field defects

Systemic signs & symptoms

Systemic infections

• Tuberculosis• Syphilis• HIV• Toxoplasmosis• Brucellosis• Herpes zoster• Candida infection

• Can affect any part of the eye

• Lids optic nerve.• Can be limited to the eye

only Difficult Dx

• Requires systemic antimicrobial therapy PLUS Steroids

• Can cause severe visual loss secondary to inflammation and infection.

Systemic infections

Retinitis with vasculitisEndogenous endophthalmitis

Systemic infections

Herpes Zoster OphthalmicusAnterior Uveitis